Antimicrobial prescribing decisions by GPs and hospital doctors have been extensively researched, and decisions by other groups such as pharmacists and nurse prescribers have also been explored. There is good evidence from systematic reviews and other empirical studies that prescribers in human medicine are influenced by a wide range of non-clinical factors. This section reviews some of this evidence and an overview of these factors is presented in Table 1.2, organised within the social ecological framework.
Table 1.2
Factors Influencing Doctors’ Antimicrobial Prescribing Decisions Social Ecological Level Influencing Factors
Intrapersonal Knowledge. Beliefs about AMR and own prescribing. Habit. Clinical experience. Cognitive biases. Emotions. Risk perceptions. Clinical uncertainty.
Interpersonal Interactions and relationships with patients. Professional relationships with peers and senior colleagues. Prescribing norms. Professional identity.
Physical Environment Time pressures. Geographic location. Lack of access to drugs, diagnostic tools, staff. Poor hygiene. Weather. Social Environment Patient socioeconomic status. Economics of healthcare
business. Pharmaceutical marketing. Guidelines. Regulations. Financial incentives.
1.7.1 Intrapersonal factors. Prescribing by doctors and other prescribers in
human medicine is influenced by various intrapersonal factors including knowledge and beliefs about AMR, risk perceptions, cognitive biases, emotions, and habit.
Knowledge and beliefs about AMR and responsible prescribing vary between doctors and in some cases are associated with prescribing patterns. For example, ignorance about the links between overprescribing and AMR, and lower levels of training, are associated with higher rates of prescribing and dispensing (Servia-
Dopazo & Figueiras, 2018; Teixeira Rodrigues et al., 2013). Although prescribers believe AMR is a serious problem that is getting worse, many believe it is a bigger problem at the global, national, or local level, compared to within their own practice (Labi et al., 2018; McCullough, Rathbone, Parekh, Hoffmann, & Del Mar, 2015; Nicholson et al., 2018). Some doctors believe that AMR is a problem that is outside their control (Broom, Broom, & Kirby, 2019; McCullough et al., 2015), and the link between their own prescribing and increased AMR is not immediately accessible or obvious during decision-making (Krockow et al., 2019). Intentions to reduce prescribing, do not, however, appear to predict doctors’ prescribing behaviour (Lambert et al., 1997; Liu, Liu, Wang, Deng, et al., 2019).
There is some evidence for the role of non-reflective cognitive processes in doctors’ prescribing. Habit is correlated with treatment decisions in primary care (Potthoff et al., 2019) and previous clinical experiences are important influences on GPs’ prescribing, especially if they have had a negative experience from withholding antimicrobials (Tonkin-Crine et al., 2011). Doctors’ diagnostic and treatment
decisions are also influenced by cognitive biases, including risk aversion, anchoring and framing effects, and confirmation bias (Saposnik, Redelmeier, Ruff, & Tobler, 2016).
Doctors’ prescribing decisions are also influenced by emotional aspects of the decision and their perceptions of risk. Clinical uncertainty means prescribing
decisions can be emotionally fraught, especially for junior doctors (Mattick, Kelly, & Rees, 2014), and fear of making the wrong decision, either for patient outcomes or for their own reputation and career, is consistently reported by prescribers across
different contexts and countries (Krockow et al., 2019; Pinder et al., 2015; Servia- Dopazo & Figueiras, 2018; Tebano et al., 2018; Teixeira Rodrigues et al., 2013; Tonkin-Crine et al., 2011). Immediate risks to patients are far more salient to prescribers than future risks from AMR (Broom et al., 2019; Hayward, Moore,
Mckelvie, Lasserson, & Croxson, 2019; Krockow et al., 2019) and doctors may be too quick to prescribe for colds if they believe antibiotics can prevent complications (Md Rezal et al., 2015). Risk perceptions also vary; for example, junior doctors report higher levels of risk perceptions than senior colleagues, meaning they may be more likely to prescribe in situations of clinical uncertainty (Krockow et al., 2019).
1.7.2 Interpersonal factors. Prescribing decisions in human medicine are
influenced by a number of interpersonal factors. Prescribers are influenced by their relationships with patients and colleagues, by prescribing norms, and by concerns about protecting their professional identities.
Interactions and relationships with patients are a key influence on prescribers’ decisions. For example, perceived pressure and expectations from patients can
increase prescribing and dispensing (Pinder et al., 2015; Sakeena, Bennett, &
McLachlan, 2018; Servia-Dopazo & Figueiras, 2018; Teixeira Rodrigues et al., 2013) and concerns about patient adherence can lead to changes in prescribing plans
(Krockow et al., 2019). Writing a prescription is sometimes seen as central to a doctor’s professional identity and to performing a successful consultation with a patient (Krockow et al., 2019; Pinder et al., 2015) and doctors may sometimes prescribe to avoid potential conflict with patients (Tonkin-Crine et al., 2011). Protecting relationships with patients and their carers is especially important to doctors working in private healthcare systems (Krockow et al., 2019). There is, however, evidence that doctors’ beliefs about patient expectations are poorly matched to patients’ actual expectations (Biezen, Grando, Mazza, & Brijnath, 2019; Cho, Soo- Jong, & Park, 2004; Coenen et al., 2013).
Colleagues also influence the decisions of prescribers, as prescribers seek to protect their professional relationships with peers, maintain or enhance their
professional identity, and conform with local prescribing norms. Relationships with other professionals such as nurses or pharmacists can influence doctors’ prescribing (Broom et al., 2019; Papoutsi et al., 2017). Supervisors and senior doctors have an especially influential role on prescribing norms in hospitals and the hierarchies that exist within and between medical teams can be a barrier to improved prescribing (Broom et al., 2019; Charani et al., 2011; Mattick et al., 2014; Papoutsi et al., 2017; Pinder et al., 2015). The opinions and actions of peers may be more important to GPs than guidelines (Tonkin-Crine et al., 2011) and hospital doctors acknowledge they sometimes just follow the routines of colleagues in their prescribing decisions (Warreman et al., 2019). Doctors may prescribe to protect their own professional reputation (Broom et al., 2019) and junior doctors are especially motivated to develop and protect their professional identities as competent doctors (Krockow et al., 2019)
as they are concerned about making prescribing errors (Mattick et al., 2014) or being criticised by senior colleagues (Papoutsi et al., 2017).
1.7.3 Physical environment factors. The physical environment within which
prescribers work can also influence prescribing decisions, with two key areas identified: time pressures and issues around access to resources.
Across all settings, time pressures are commonly mentioned by doctors as influencing their prescribing (Liu, Liu, Wang, & Zhang, 2019; Mattick et al., 2014; Pinder et al., 2015; Teixeira Rodrigues et al., 2013). Prescribing can be a way of managing consultations and keeping them short (Tonkin-Crine et al., 2011) and can help reduce the cognitive demands of decision-making when doctors are under time pressures (Krockow et al., 2019). The time of day and week may also be important; prescribing rates and appropriateness can differ throughout the day (Linder et al., 2014; Sikkens, Gerritse, et al., 2018) and GPs may be more likely to prescribe antimicrobials on a Friday (Salm et al., 2018) although this pattern is not always in evidence (Pouwels, Dolk, Smith, Robotham, & Smieszek, 2018).
Access to various healthcare resources can also affect prescribing decisions. There are differences in prescribing patterns within countries (Mölter et al., 2018) and working in a rural location, which can bring issues such as staff shortages and lack of resources, is associated with higher and less appropriate antimicrobial prescribing (Bishop et al., 2019; Broom et al., 2019; Liu, Liu, Wang, & Zhang, 2019). Diagnostic tools are not always routinely used or used in line with recommendations (Livorsi, Comer, Matthias, Perencevich, & Bair, 2016; Skodvin et al., 2019), and the time delays in receiving diagnostic results are often cited as a barrier to increased use of diagnostics (Krockow et al., 2019; Skodvin, Aase, Charani, Holmes, & Smith, 2015). Lack of access to diagnostic equipment is often an issue in LMICs (Laxminarayan et al., 2013; Om et al., 2016), but can also be a barrier in HICs, for example in contexts such as long-term care facilities (Fleming et al., 2014). In addition to access issues with drugs and other resources (Laxminarayan et al., 2013; Om et al., 2016), prescribers in LMICs can be faced with additional challenges around poor hygiene and IPC practices both within the community and healthcare settings (Om et al., 2016; Review on AMR, 2016a). Finally, climatic and weather conditions can influence the general disease burden in a given population, which in turn can influence the demands
upon local healthcare facilities for antimicrobials (Sahoo, Tamhankar, Johansson, & Stålsby Lundborg, 2010).
1.7.4 Social environment factors. Finally, the social environment also
influences prescribing decisions in human medicine. Influencing factors include patient socioeconomic status, healthcare business pressures, pharmaceutical marketing, guidelines, regulations, and financial incentives.
Economic factors, such as the patient’s socioeconomic status or business revenues, can affect prescribing decisions. For example, antimicrobials may be seen by prescribers as a low-cost method of managing consultations and conditions (Pinder et al., 2015; Teixeira Rodrigues et al., 2013) and the economic and social situation of a patient can influence prescribing and dispensing (Mölter et al., 2018; Pinder et al., 2015; Servia-Dopazo & Figueiras, 2018; Teixeira Rodrigues et al., 2013). Pharmacy owners sometimes exert pressure on their workers to dispense inappropriately and workers may also dispense based on financial benefit to the pharmacy (Sakeena et al., 2018; Servia-Dopazo & Figueiras, 2018). Furthermore, marketing and pressure from pharmaceutical companies can influence prescribing decisions, although this is not always the case (Md Rezal et al., 2015; Teixeira Rodrigues et al., 2013).
The presence (or absence) of guidelines, regulations, and financial incentives can also impact on prescribing decisions, but the existence of guidelines and
regulations does not always lead to greater antimicrobial stewardship by doctors and other prescribers. For example, weak regulation of medicines and a shortage of qualified pharmacists is associated with inappropriate sales in some LMICs (Sakeena et al., 2018) and the introduction of new regulations does not always drive anticipated changes in prescribing patterns (Touboul-Lundgren, Bruno, Bailly, Dunais, & Pradier, 2017; Xiao et al., 2016). In both HICs and LMICs, prescribing guidelines and policies are not consistently used by prescribers, nor is the existence of guidelines consistently associated with responsible prescribing (Livorsi et al., 2016; Md Rezal et al., 2015; Tafa, Endale, & Bekele, 2017; Teixeira Rodrigues et al., 2013). There is evidence that doctors may be sceptical of guidelines (Om et al., 2016; Pinder et al., 2015; Tonkin- Crine et al., 2011) and that prescribers exercise clinical judgement over guidelines (Charani et al., 2011; Fleming et al., 2014; Pinder et al., 2015). Some doctors feel stewardship policies do not fully recognise case complexity and in some instances are seen as largely irrelevant (Broom et al., 2019). Regulatory obligations to reduce
healthcare-associated infections and implement antimicrobial stewardship guidelines, as well as financial penalties or incentives linked to infection and stewardship targets, can be effective in driving changes in prescribing patterns (Islam et al., 2018; PHE, 2019; Trivedi, Dumartin, Gilchrist, Wade, & Howard, 2014).
1.7.5 Summary. This section has briefly outlined how antimicrobial
prescribing decisions in human medicine are influenced by a range of factors across the intrapersonal, interpersonal, physical environment, and social environment levels of the social ecological framework. The next section considers how antimicrobial usage decisions by the general public are influenced across these four levels.